Jun Minakuchi

2011 update Japanese Society for Dialysis Therapy Guidelines of Vascular Access Construction and Repair for Chronic Hemodialysis

Abstract:  The guideline committee of Japanese Society for Dialysis Therapy (JSDT), chaired by Dr Ohira, has published an original Japanese guideline, ‘Guidelines for Vascular Access Construction and Repair for Chronic Hemodialysis’. The guideline was created mainly because of the existence of numerous factors characteristic of Japanese hemodialysis therapy, which are described in this report, and because we recognized the necessity for standardization in vascular access‐related surgeries. This guideline consists of 10 chapters, each of which includes guidelines, explanations or comments and references. The first chapter discusses informed consent of vascular access (VA)‐related surgeries, which often resulted in trouble between dialysis staff and patients. The second chapter describes the fundamentals of VA construction and timing of the introduction of hemodialysis with emphasis on the avoidance of catheter indwelling if at all possible. In the third chapter, arteriovenous fistula (AVF) construction and management are discussed from the viewpoint of the most preferable type of VA. The fourth chapter deals with arteriovenous grafts (AVG) which has recently increased in clinical applications. The factors which improve the AVG patency rate are discussed and postoperative management methods are emphasized to avoid possible complications. The fifth chapter deals with short and long‐term vascular catheters. It is emphasized that these methods are definitely effective but, at the same time, are apt to be associated with several serious complications and might result in vascular damage. In the sixth chapter, superficialization of an artery is explained. This was originally for emergency use or backup but has been used permanently in 2–3% of Japanese hemodialysis patients. In the seventh chapter, methods for the use of VA are described and the buttonhole method is referred to as one of the options for patients who complain of intense pain at every cannulation. In the eighth chapter, the importance of continuous monitoring is stressed for maintaining appropriate function of VA. As a rule, the internal shunt type VA (AVF, AVG) places a burden on cardiac function. Thus, in the ninth chapter, it is stressed that VA construction, maintenance and repair should always be carried out with consideration of cardiac function which is not constant but variable. The 10th chapter forms one of the cores of this guideline and deals with repair and timing of VA. It is shown how to select a surgical or interventional repair method. In the final 11th chapter, VA types and resultant morbidity and mortality of hemodialysis patients are reviewed.

2011 update Japanese Society for Dialysis Therapy Guidelines of Vascular Access Construction and Repair for Chronic Hemodialysis: 2011 JSDT Guidelines

Abstract:  The guideline committee of Japanese Society for Dialysis Therapy (JSDT), chaired by Dr Ohira, has published an original Japanese guideline, ‘Guidelines for Vascular Access Construction and Repair for Chronic Hemodialysis’. The guideline was created mainly because of the existence of numerous factors characteristic of Japanese hemodialysis therapy, which are described in this report, and because we recognized the necessity for standardization in vascular access-related surgeries. This guideline consists of 10 chapters, each of which includes guidelines, explanations or comments and references. The first chapter discusses informed consent of vascular access (VA)-related surgeries, which often resulted in trouble between dialysis staff and patients. The second chapter describes the fundamentals of VA construction and timing of the introduction of hemodialysis with emphasis on the avoidance of catheter indwelling if at all possible. In the third chapter, arteriovenous fistula (AVF) construction and management are discussed from the viewpoint of the most preferable type of VA. The fourth chapter deals with arteriovenous grafts (AVG) which has recently increased in clinical applications. The factors which improve the AVG patency rate are discussed and postoperative management methods are emphasized to avoid possible complications. The fifth chapter deals with short and long-term vascular catheters. It is emphasized that these methods are definitely effective but, at the same time, are apt to be associated with several serious complications and might result in vascular damage. In the sixth chapter, superficialization of an artery is explained. This was originally for emergency use or backup but has been used permanently in 2–3% of Japanese hemodialysis patients. In the seventh chapter, methods for the use of VA are described and the buttonhole method is referred to as one of the options for patients who complain of intense pain at every cannulation. In the eighth chapter, the importance of continuous monitoring is stressed for maintaining appropriate function of VA. As a rule, the internal shunt type VA (AVF, AVG) places a burden on cardiac function. Thus, in the ninth chapter, it is stressed that VA construction, maintenance and repair should always be carried out with consideration of cardiac function which is not constant but variable. The 10th chapter forms one of the cores of this guideline and deals with repair and timing of VA. It is shown how to select a surgical or interventional repair method. In the final 11th chapter, VA types and resultant morbidity and mortality of hemodialysis patients are reviewed.

Japanese Society for Dialysis Therapy Clinical Guideline for “Maintenance Hemodialysis: Hemodialysis Prescriptions”

Yuzo Watanabe, Hideki Kawanishi, Kazuyuki Suzuki, Shigeru Nakai, Kenji Tsuchida, Kaoru Tabei, Takashi Akiba, Ikuto Masakane, Yoshiaki Takemoto, Tadashi Tomo, Noritomo Itami, Yasuhiro Komatsu, Motoshi Hattori, Michio Mineshima, Akihiro Yamashita, Akira Saito, Hidemune Naito, Hideki Hirakata, and Jun Minakuchi, for “Maintenance Hemodialysis: Hemodialysis Prescriptions” Guideline Working Group, Japanese Society for Dialysis Therapy

Japanese Society for Dialysis Therapy Clinical Guideline for “Hemodialysis Initiation for Maintenance Hemodialysis”

Yuzo Watanabe, Kunihiro Yamagata, Shinichi Nishi, Hideki Hirakata, Norio Hanafusa, Chie Saito, Motoshi Hattori, Noritomo Itami, Yasuhiro Komatsu, Yoshindo Kawaguchi, Kazuhiko Tsuruya, Yoshiharu Tsubakihara, Kazuyuki Suzuki, Ken Sakai, Hideki Kawanishi, Daijo Inaguma, Hiroyasu Yamamoto, Yoshiaki Takemoto, Noriko Mori, Kazuyoshi Okada, Hiroshi Hataya, Takashi Akiba, Kunitoshi Iseki, Tadashi Tomo, Ikuto Masakane, Tadao Akizawa, and Jun Minakuchi, for “Hemodialysis Initiation for Maintenance Hemodialysis” Guideline Working Group, Japanese Society for Dialysis Therapy

Cost-Effectiveness Analysis of On-Line Hemodiafiltration in Japan

Background/Aims: Evaluation of the socioeconomic value of medical intervention and establishment of the resources necessary for clinical practice are important for new developments in medical technology. The aim of this study was to determine the socioeconomic value of on-line hemodiafiltration (HDF). Methods: The subjects were 24 patients who underwent hemodialysis (HD) (9 HDF, 15 HD) for chronic renal failure. A total of 288 dialysis interventions were observed for 4 weeks in three clinics. Cost-effectiveness was evaluated based on quality-adjusted life years (Qaly) and a visual analog scale. Results: EuroQOL-5D (0.776 ± 0.015) and visual analog scale (67.9 ± 1.2) in the HDF group were higher than those in the HD group at baseline. The incremental cost utility ratio for HDF was 641.7 (JPY 10,000/Qaly) based on Qaly (0.776 ± 0.015) and reimbursement for medical fees (JPY 4,982,736 ± 7,852), and was lower than the incremental cost utility ratio for HD. Conclusion: These results suggest that on-line HDF could be cost-effective.

Clinical Benefits of Predilution On-Line Hemodiafiltration

There are two types of hemodiafiltration (HDF) treatments, predilution and postdilution. In Japan, clinical doctors have been using the on-line HDF treatment for renal replacement therapy for 20 years. However, this treatment is not popular in Japan because it has not been recognized by the government. Generally, the advantage of postdilution HDF over predilution HDF resides in the fact that it removes low-weight molecular proteins (LWMPs) and protein-binding uremic toxin. Thus, postdilution on-line HDF has been widely used in the world, but in Japan predilution on line-HDF has been the preferred treatment. There are several reasons why predilution on-line HDF has been the preferred treatment in Japan. Predilution on-line HDF is superior to postdilution on-line HDF in removing LWMPs and protein-binding uremic toxin, for example p-cresol and homocysteine. In addition, there are several reports on the biocompatibilities in predilution on-line HDF. Predilution on-line HDF is associated with reduced shear stress, and the synthesis of cytokine and cellular adhesion molecules. Moreover, with predilution on-line HDF/hemofiltration, blood pressure remains stable during treatment. In Japan, over 90% of dialysis patients have been receiving hemodialysis (HD) therapy with the ultra-high flux dialysis membrane. These ultra-high flux dialysis membranes achieve β2-microglobulin clearance rates of >50 ml/min. In addition, these membranes have the same power as postdilution HDF because they allow automatic internal filtration. Thus, in spite of HD treatment, as a result, the effect is the same as with postdilution HDF treatment. There have been small and retrospective studies on predilution on-line HDF, and we must use a hemodiafilter during the on-line HDF treatment. However, the hemodiafilter has been unsuccessful in reaching the LWMP removal rates which we demand. And the most important point is to carry out a prospective multicenter randomized controlled trial of predilution on-line HDF in the near future.

Shortened Red Blood Cell Lifespan Is Related to the Dose of Erythropoiesis-Stimulating Agents Requirement in Patients on Hemodialysis

Renal anemia is an important complication of chronic kidney disease (CKD). One of the most important complications of renal anemia is reduced red blood cell (RBC) lifespan, but there has been little research conducted into the causes of and treatments for this anemia. We measured alveolar carbon monoxide (CO) and then estimated RBC lifespan in patients on hemodialysis (HD). We also examined their requirement for erythropoiesis‐stimulating agents (ESA), HD dose, nutrition factors, iron metabolism factor, reticulocyte counts and % reticulocytes. We enrolled 140 patients undergoing intermittent HD; among this group, 31 were not administered ESA and the others were on ESA therapy. Twelve healthy volunteers served as controls. The RBC lifespans in the healthy volunteers and in the HD patients were 128 ± 28 and 89 ± 28 days (mean ± SD), respectively. The RBC lifespan significantly and negatively correlated with ESA requirement (r = −0.489, P < 0.0001) in the HD patients. Other factors suspected to influence the RBC lifespan did not significantly correlate with the RBC lifespan in HD patients, in contrast to the correlation observed for S‐Cr, BUN, S‐ALB and total cholesterol vs. RBC lifespan. A shortened RBC lifespan seems to rather significantly affect the ESA requirement. Better nutritional status or active HD patients also seem to have longer RBC lifespans and lower ESA requirement.

Proposal for the Shared Decision-Making Process Regarding Initiation and Continuation of Maintenance Hemodialysis

Yuzo Watanabe, Hideki Hirakata, Kazuyoshi Okada, Hiroyasu Yamamoto, Kazuhiko Tsuruya, Ken Sakai, Noriko Mori, Noritomo Itami, Daijo Inaguma, Kunitoshi Iseki, Akiko Uchida, Yoshindo Kawaguchi, Seiji Ohira, Masashi Tomo, Ikuto Masakane, Tadao Akizawa, and Jun Minakuchi, for the Japanese Society for Hemodialysis Therapy Guideline Commission of Maintenance Hemodialysis Investigation Subgroup Commission on Withholding and Withdrawal from Dialysis

Implications of Albumin Leakage for Survival in Maintenance Hemodialysis Patients: A 7‐year Observational Study

Albumin leakage during hemodialysis (HD) presents a clinical dilemma. However, protein‐binding uremic toxins are suggested to be responsible for increased mortality. No one has investigated the relationship between albumin leakage and mortality. Therefore, the purpose of this observational study was to analyze the association of albumin leakage with mortality in 690 HD patients who survived one year after enrollment. They were divided to three groups who received HD with large (3 g or more per HD session), middle (1 to 3 g) or small (less than 1 g) amount of albumin leakage, respectively. A propensity score analysis minimizing indication bias was performed. Consequently, in a 7‐year observation period, 212 patients died. Albumin leakage 3 g or more per HD session provided better prognosis than albumin leakage less than 3 g per HD session. In conclusion, clinically acceptable large albumin leakage provides beneficial effects on mortality in maintenance HD patients.

Treatment of renal anaemia with erythropoiesis-stimulating agents in predialysis chronic kidney disease patients: Haemoglobin profile during the 6 months before initiation of dialysis

Erythropoiesis‐stimulating agents (ESAs) are all effective for renal anaemia in patients with chronic kidney disease (CKD). However, it was reported that the haemoglobin (Hb) concentration decreases to 8.4 g/dL during the initial phase of dialysis despite treatment with recombinant human erythropoietin (rHuEPO). This study compared Hb at the initiation of dialysis among patients treated with three different ESAs (rHuEPO, darbepoetin alfa [DA], and a continuous erythropoietin receptor activator [CERA]).